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Section 15
Treatment for Child Conduct Problems

Question 15 | Test Table of Contents


Young preschool and early-school-age children with early onset conduct problems are at high risk for school dropout, substance abuse, violence, and delinquency in later years. Consequently, developing treatment strategies for reducing conduct problems when aggression is in its more malleable form prior to age 8, and thus interrupting its progression, is of considerable benefit to families and society. This article describes a treatment program—the Dina Dinosaur Social, Emotional and Problem Solving Child Training Program—that was designed specifically with developmentally appropriate teaching methods for young children (ages 4 to 8 years) and based on theory related to the types of social, emotional, and cognitive deficits or excesses exhibited by children with conduct problems. The program emphasizes training children in skills such as emotional literacy, empathy or perspective taking, friendship and communication skills, anger management, interpersonal problem solving, school rules, and how to be successful at school. Emphasis is placed on ways to promote cross-setting generalization of the behaviors that are taught by involving parents and counselors in the treatment.

Program Content And Goals
The Dina Dinosaur Treatment Program targets children with conduct problems, but it is also appropriate for addressing comorbid problems such as attention problems and peer rejection. The curriculum consists of 18 to 22 weekly 2-hour lessons. It can be delivered by counselors or therapists in a mental health–related field or by early childhood specialists who have experience treating children with conduct disorders or early-onset behavior problems. Therapists receive extensive training in the content and methods of the treatment program. They use comprehensive group leader manuals that describe each session’s content, objectives, videotapes to be shown, and small-group activities. Treatment integrity is monitored through session-by-session protocols and unit checklists completed by therapists as well as by supervisor and peer videotape reviews. This program is an ideal companion to the Incredible Years parent programs. The 22-session parent group and the child training group can be offered concurrently. (This arrangement also helps with parents’ childcare needs, so the parents can attend parent sessions knowing their children are well cared for.) In the material to follow, we provide a brief description of and rationale for each of the treatment components (see Note).

Detective Wally Teaches Problem-Solving Steps (Stegosaurus Program)
Children who are hyperactive, impulsive, inattentive, and aggressive have been shown to have cognitive deficits in key aspects of social problem solving (Dodge & Crick, 1990). Such children perceive social situations in hostile terms, generate fewer prosocial ways of solving interpersonal conflict, and anticipate fewer consequences for aggression (Dodge & Price, 1994). They act aggressively and impulsively without stopping to think of nonaggressive solutions or of the other person’s perspective, and they expect their aggressive responses to yield positive results. There is evidence (Dodge, Pettit, & Bates, 1994) that children who employ appropriate problem-solving strategies play more constructively, are better liked by their peers, and are more cooperative at home and school. Consequently, in this next program of the intervention, therapists teach children to generate more prosocial solutions to their problems and to evaluate which solutions are likely to lead to positive consequences. In essence, these children are provided with a thinking strategy that corrects the flaws in their decision-making process and reduces their risk of developing ongoing peer relationship problems. Children learn a seven-step problem-solving process: 1. How am I feeling, and what is my problem? (define problem and feelings) 2. What is a solution? 3. What are some more solutions? (brainstorm solutions) 4. What are the consequences? 5. What is the best solution? (Is the solution safe? fair? Does it lead to good feelings?) 6. Can I use my plan? 7. How did I do? (evaluate outcome and reinforce efforts)

A great deal of time is spent on Steps 1, 2, and 3 to help the children increase their repertoire of possible prosocial solutions (e.g., trade, ask, share, take turns, wait, walk away, take a deep breath). In fact, for the 3- to 5-year-olds, these three steps may be the entire focus of the unit. One to two new solutions are introduced in each session, and the children are given multiple opportunities to role play and practice these solutions with a puppet or another child. Laminated cue cards with pictures of more than 40 solutions are provided in Wally’s “detective kit” and are used by the children to generate possible solutions and evaluate whether they will work to solve particular problems. Children role play solutions to problem scenarios introduced by the puppets, the video vignettes, or the children themselves. In one activity, the children draw or color their own solution cards so that each child has his or her own detective solution kit by the end of the unit. The children are guided to consult their own or the group solution kit when a real-life problem occurs. Activities for this program include writing and acting in a problem-solving play, going “fishing” for solutions (with a magnetized fishing rod), and working as a group to generate enough solutions to join Wally’s Problem-Solving Detective Club.

Detective Wally Teaches Problem-Solving Steps (T-Rex Program)
Aggression and inadequate impulse control are perhaps the most potent obstacles children with conduct problems face with regard to effective problem solving and forming successful friendships. Without help, these children are more likely to experience ongoing peer rejection and continued social problems for years afterwards (Coie, 1990). Such children have
difficulty regulating their negative affect in order to generate positive solutions to conflict situations. Furthermore, there is evidence that aggressive children are more likely to misinterpret ambiguous situations as hostile or threatening. This tendency to perceive hostile intent in others has been seen as one source of their aggressive behavior (Walker, Colvin, & Ramsey, 1995). Consequently, once the basic skills for problem solving have been acquired, the children are taught anger management strategies. Anger management programs based on the work of Novaco (1975) have been shown to reduce aggression in aggressive middle and high school clients and to maintain gains in problem-solving skills (Lochman & Dunn, 1993). Clearly children cannot solve problems if they are too angry to think calmly. A new puppet, Tiny Turtle, is used to teach the children a five-step anger management strategy: 1. Recognize anger. 2. Think “stop.” 3. Take a deep breath. 4. Go into your shell and tell yourself, “I can calm down.” 5. Try again.

Tiny’s shell is the basis for many activities: making a large cardboard shell that children can actually hide under, making grocery bag “shells” or vests, molding Playdough shells for small plastic figures (the children pretend the figures are mad and help them to calm down in the Playdough shells), and making teasing shields. Each of these activities provides multiple opportunities for the therapist to help the children practice the steps of anger management. Children learn to recognize the clues in their bodies that tell them they are getting angry, and to use self-talk, deep breathing, and positive imagery to help themselves calm down. Therapists also use guided imagery exercises with the children (having them close their eyes and pretend to be in a cocoon or turtle shell) to help them experience the feelings of being relaxed and calm. Videotapes of children handling anger, being teased, or being rejected are used to trigger role plays to practice these calming strategies. In addition, the puppets talk to the children about problems (e.g., a parent or counselor was mad at them for a mistake they made, they were left out of a birthday party, a parent is getting divorced or doing something that disappoints them). The situations that the puppets bring to the group are formulated according to experiences and issues relevant to particular children in the group. For example, if a child in the group is teased at school (and is reacting in an aggressive or angry way), Wally might tell the group that someone at school called him a name and Wally was so mad that he hit the person. Wally would then talk about the consequences of hitting (he felt bad afterwards, and he got in trouble). The group would then generate alternative solutions for Wally and would help him practice them. The child who has this same difficulty at school would often be chosen to act out an appropriate solution with Wally.

Throughout the discussion of vignettes and role-play demonstrations, the therapists and puppets help the children to change some of their attributions about events. For example, Molly Manners (Wally’s sister) explains, “Maybe he was teasing you because he really wanted to be your friend but didn’t know how to ask you nicely” or, “You know, all kids get turned down sometimes when they want to play; it doesn’t mean they don’t like you” or, “I think that it was an accident that he bumped into you.” The Pass the Hat Detective Game is played to help the children determine when an event might be an “accident” versus when it might be done “on purpose” and how each event could be handled.

Molly Manners Teaches How to Be Friendly (Allosaurus and Brachiosaurus Programs)
Children with conduct problems have particular difficulty in forming and maintaining friendships. Our research, and that of others, has indicated that these children have significantly delayed play skills, including difficulties waiting for a turn, accepting peers’ suggestions, offering an idea rather than demanding something, or collaborating in play with peers (Webster-Stratton & Lindsay, 1999). They also have poor conversation skills, difficulty in responding to the overtures of others, and poor group-entry skills. Consequently, in the friendship program we focus on teaching children a repertoire of friendly behaviors such as sharing, taking turns, asking, making a suggestion, apologizing, agreeing with others, and giving compliments. In addition, the children are taught specific prosocial responses for common peer situations. An example would be entering a group of children who are already playing: 1. Watch from the sidelines and show interest. 2. Continue watching and give a compliment. 3. Wait for a pause. 4. Ask politely to join in and accept the response.

As with other new material, the children see these friendship skills modeled by the puppets or in videotape examples and practice using them in role plays and cooperative games.

Integration of Cognitive, Affective, and Behavioral Components
Each unit uses this combination of cognitive, affective, and behavioral components to enhance learning. For example, the anger thermometer is used to teach children self-control and to monitor their emotional state. Children decorate the thermometer with pictures of feeling faces from “happy” and “relaxed” in the blue (or cool) section of the thermometer all the way up to “angry” or “stressed out” in the red (or hot) section of the thermometer. The therapist can then ask a child to describe a recent conflict, and together they retrace the steps that led to the angry outburst. The therapist writes down the child’s thoughts, feelings, and actions that indicated an escalating anger pattern, for example, “He always takes my toys” (thought), “That really makes me mad” (feeling). “I got so mad that I kicked him” (action). The therapist and the child discuss thoughts, words, and actions that the child can use to reduce his or her anger. As the therapist retraces the steps of the angry outburst, she or he helps the child identify the place where the child was aware that he or she was getting angry. This is marked as the “Danger Point” on the thermometer. Once the child has established this danger point, he or she chooses a name that will be the signal for reaching that point (e.g., chill out, cool down, code red, hot engine). This code word will be the counselor and child’s signal that anger or stress has reached the threshold and will trigger the use of an agreed-upon calming strategy, such as taking three deep breaths.

Fantasy Play and Instruction
Fantasy play provides the context for this program because a high level of sociodramatic play in early-school-age children is associated with sustained and reciprocal verbal interactions and high levels of affective role taking (Connolly & Doyle, 1984). Fantasy play gives children the opportunity to develop intimacy and work out emotional issues (Gottman, 1983). For preschool-age children, sociodramatic play is an important context in which perspective taking, social participation, group cooperation, and intimacy skills develop. This important skill can easily be fostered through the use of the child-sized human puppets.

Promoting Skills Maintenance and Generalization
Because the children are learning these skills in a setting removed from the classroom and home environments, the therapists must do everything they can to promote generalization of skills to other settings. Therapists should look for opportunities to praise and coach prosocial behavior even during less structured times, such as in the waiting room before the group starts, snack time, bathroom breaks, and transitions. For each main intervention component, parents and counselors are sent letters explaining the content of the unit (e.g., expressing feelings, sharing, problem solving) and suggesting ways they can reinforce these behaviors at home and at school. Several times during the program, phone calls are made to parents and counselors to tell them about the children’s successes, which behaviors to reinforce, and which ones to ignore. Parents and counselors need to offer praise and reinforcement whenever they see the children using these prosocial behaviors in naturally occurring settings. The homework assignments, which children complete with parents each week, also reinforce these concepts and help parents to learn and understand the same terminology that their children are using in Dinosaur School so that there is cross-setting consistency in responses from therapists and parents.

Group Management
The implementation of the Dinosaur program is dependent on the variety of therapeutic processes and methods described in this article. A final key element of successful group therapy with children who have conduct problems is utilizing research-based group-management strategies (e.g., incentives and time out; Brophy, 1996). In order to be able to teach these difficult children and provide a safe environment for them, the therapists must manage oppositional and aggressive behaviors extremely well. Research has shown that when children with conduct problems are placed in groups, they may reinforce each other’s antisocial behaviors and actually become worse instead of better if their negative behaviors are not managed well (Dishion, McCord, & Poulin, 1999). A well-managed group with consistent rules and limits can provide these children with one of the first opportunities they have ever had to be successful in a learning environment with their peers. In fact, after an initial testing period, most children with conduct problems who participate in these groups enjoy coming to group, follow the rules consistently, and make some of the first positive friendships they have ever had. Group leaders work together, and in consultation with parents and classroom counselors, to develop individual behavior plans for each child in the group. Thus, although all of the children are expected to follow basic group rules, one child may have a special program designed to decrease rude talk, another child might be working on remembering to think before impulsively blurting out answers, and a third child might be working on listening carefully to adult instructions. In this way, the particular issues of each child can be addressed in a group context.
- Webster-Stratton, Carolyn and Jamia M. Reid, Treating Conduct Problems and Strengthening Social and Emotional Competence in Young Children: The Dina Dinosaur Treatment Program; Journal of Emotional & Behavioral Disorders, Fall2003, Vol. 11 Issue 3, p130, 14p

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about the “Dina Dinosaur” Treatment Program. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Dadds, M. R., Thai, C., Mendoza Diaz, A., Broderick, J., Moul, C., Tully, L. A., Hawes, D. J., Davies, S., Burchfield, K., & Cane, L. (2019). Therapist-assisted online treatment for child conduct problems in rural and urban families: Two randomized controlled trials. Journal of Consulting and Clinical Psychology, 87(8), 706–719.

Porta, C. M., Bloomquist, M. L., Garcia-Huidobro, D., Gutiérrez, R., Vega, L., Balch, R., Yu, X., & Cooper, D. K. (2018). Bi-national cross-validation of an evidence-based conduct problem prevention model. Cultural Diversity and Ethnic Minority Psychology, 24(2), 231–241.

Salmanian, M., Ghobari-Bonab, B., Hooshyari, Z., & Mohammadi, M.-R. (2020). Effectiveness of spiritual psychotherapy on attachment to God among adolescents with conduct disorder: A randomized controlled trial. Psychology of Religion and Spirituality, 12(3), 269–275.

QUESTION
According to Webster-Stratton, what is the function of an “anger thermometer?” To select and enter your answer go to Test.

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